28 yr old male with chest pain

 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

Chief complaints:

36 year old male, resident of suryapet came to the OPD with the Cheifcomplaints of  increased alcohol consumption since 2 yrs (daily 25units since 2 months) and increased cigarette smoking since 2 yrs(daily 20 cigarettes)

HOPI: Patient had habit of consuming alcohol occasionally 2years back ,but increased then after due to family and financial stressors to 25units

Binge drinking of continuously 15days then stops as he falls I’ll get treatment from local RMP nearby,again start consuming alcohol from the day he becomes well

Tolerance present

Sleep disturbance,tremors,sweating early in the morning after consuming alcohol in the night(eye opener present)

Loss of control present

Blood in vomitus 3 months back

H/o black colored stools 1 week back

Past history:

N/K/C/O HTN,DM,TB,CAD,ASTHMA

GENERAL EXAMINATION 

Patient is Conscious, coherent,co operative well oriented to Time,place,person

No pallor, No icterus, No Cyanosis, No Lymphadenopathy, No Edema

VITALS

Temperature -98F

Pulse rate- 90bpm

Blood pressure-110/70mm hg

Respiratory rate -16cpm

SYSTEMATIC EXAMINATION:

PER ABDOMEN:Soft, non tender

No guarding, No rigidity 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

S1,S2 heard, NO Murmurs 

RESPIRATORY SYSTEM:

BAE present,NVBS

CENTRAL NERVOUS SYSTEM:

NAD

PROVISIONAL DIAGNOSIS-ALCOHOL DEPENDENCE SYNDROME WITH TOBACCO DEPENDENCE SYNDROME 

INVESTIGATIONS 

LFT:

TB :0.81

DB:0.9

SGOT :29

SGPT:56

ALP: 122

TP:6.6gm/dl

ALBUMIN-3.2gm/dl

A/G-0.96

RBS-76mg/dl

TREATMENT 

1.TAB BENXL

2.TAB BACFENXL 20mg

3.NICOTEX GUMS 4 mg

4.Sitz bath with betadine BD

5.High fibre diet